1颗子弹，10年创痛

The surgeons were almost three hours into their work on their extravagantly tattooed patient, Dustin E. Kirby, when they started the first cut through his jaw. Guided by a plastic jig, Dr. Stephanie Teng, a resident at Lenox Hill Hospital in Manhattan, pushed the reciprocating blade of a small electric hand saw through the bone. The blade protested as it moved, its pitch rising to a slight grinding whine, until the bone parted.

Almost 10 years after he was shot through the mouth, Kirby, a veteran of the Iraq War, was having his face overhauled again, the latest stop on what will be a lifelong tour of the damage a single bullet can do.

In the hours leading up to this moment, the surgical team, led by Dr. David L. Hirsch, the reconstruction director of maxillofacial surgery at the New York Head and Neck Institute, had removed the metal hardware that for years held Kirby’s previously shattered bones in place. This was a tedious undertaking of backing out rows of titanium screws that fastened the old plates to his bullet-wrecked jaw. It was a job accomplished with metal mallets, screwdrivers and a power drill — a process that resembled, in living tissue and in miniature, removing a sagging and overgrown front deck from an otherwise well-loved house.

在这一刻之前的几个小时里，由纽约头颈研究所(New York Head and Neck Institute)的上颌面外科整形主任大卫·L·赫希医生(Dr. David L. Hirsch)领导的手术小组去掉了几年来支撑着柯比破碎骨头的金属支架。一排排钛螺钉固定着他因子弹受损的下巴上的旧托板，这项繁琐的工作就是要把这些螺钉拆掉，需要使用金属锤、螺丝刀和电钻。整个工序有点像从一栋本来很讨人喜欢的房子上拆除塌陷冗余的前廊，只不过是在活体组织上进行，而且精微细致得多。

The nurses dropped the outgoing metal into a plastic cup, screw by bloody screw. Now came an afternoon of controlled trauma, as the surgeons continued breaking the jaw with precision cuts and then realigned Kirby’s profile and bite by pulling the mandible forward, up and to his right. This they fixed in place with fresh screws and a long, curved, custom-fitted titanium plate, which Hirsch had prefashioned through a computer-assisted design process called virtual surgical planning. With the follow-up procedures and rows of dental implants to come, the final results were intended to change how Kirby eats, talks, smiles, laughs, kisses and looks — in short, to change how a disfigured man experiences life.

Kirby is known as Doc, a reference to his former duties as a Navy corpsman assigned to a Marine Corps infantry battalion in Karma, Iraq, a small but especially violent town in Anbar Province. I first met him in the fall of 2006 with Joao Silva, a New York Times photographer; one day on a raid we were present as he saved the life of a Marine, Colin Smith, who had been shot through the skull. Kirby’s own turn as a battlefield patient came on Christmas Day that year, when he was 22. He was standing on a rooftop when a single shot found him. The bullet entered through his left cheek and exited his right. Along the way it ripped out part of his tongue and seven teeth, and shattered the right side of his jaw. It also cracked part of his lower skull, near the roof of his mouth, and damaged his sinuses.

Doc knew none of this at the time. What he knew was that he had been hit, that his mouth was so full of blood and loose tissue that he could not talk and that if he did not act quickly and decisively he would die. Using his own knife, he pushed a blade into the base of his neck — opening a makeshift airway that bypassed the sputtering mess behind his chin.

The tracheotomy ensured his breathing would be maintained, at least for a short while. His wounds carried another set of immediate risks: Because of their location, there was no way for a tourniquet to stop his bleeding. By the time a helicopter had carried him to a military hospital, he was struggling for consciousness. As the doctors leaned over and the anesthetic fog carried him away, he assumed that he was dead.

The first medical team saved his life. In the years that followed, other teams undertook the tasks of rebuilding his face. Surgeons removed his right fibula and grafted a portion of it to the right side of his jaw. They installed titanium plates to reinforce his hybrid mandible and give it shape. He began speech therapy so he could relearn to talk, and psychological counseling so he might unpack his experience of being wounded and its particular effects on him, and adjust to a life different from what he had ever imagined.

From a distance, at a glance, Doc’s case could seem a success. In most any other war, most any other context, the bullet that blew out the right side of his face would have taken with it his life. Instead, Doc took his place in the long, scarred line of living exhibits showing how the American military was rushing gravely wounded troops from the battlefield and treating them with skills and confidence no American fighting force had known before. In 2007, he was back in the States, still in uniform, helping to train new corpsmen for the combat lifesaving skills they would need in Afghanistan and Iraq. All the while doctors kept working on his face.

Those who knew Doc well understood that his recovery did not proceed as far as he hoped, and that the neat stories of maimed but rebounding veterans, a feel-good genre of the period, did not quite apply to him. Doc had dodged death to face a cascade of problems: chronic pain, migraines, PTSD, insomnia. His rebuilt jaw did not line up with his teeth. He retained enough of his tongue that he was able to compensate for speech, but the altered shape of his oral cavity and the damage to his tongue made eating difficult. Sometimes he had to chew food on one side of his mouth, then manipulate it toward his throat with his left index finger. By 2008 his brief marriage had ended. Within a few years he racked up 32 operations. He was jumpy, brooding and self-conscious. To manage pain and sleeplessness, and the loneliness, he took to drinking, sometimes to a restless stupor.

When he was medically discharged from the Navy in 2012, he was stripped of a sense of purpose and belonging. When I visited him that spring, he began drinking before we ate lunch. New physical problems presented themselves, in forms only a person who has suffered a devastating wound to the mouth can know – bits of teeth loosened and dropped out, later followed by a chunk of bone and a screw. Doc gained weight, added tattoos and grew a beard, which partly hid the fact that his jaw, his teeth and his mouth were getting worse.

By last year he had dialed back his drinking, was in a new relationship and had become a father. But still he struggled to move forward, and his confidence in the Department of Veterans Affairs plummeted. As his dental pain became unbearable, he called for appointments. The V.A. offered him tooth extractions, he and his mother said, after a wait of several months. Tooth extractions were never going to be enough.

Doc sensed that his government-funded facial reconstruction had crested, and now was failing. He had no plan. Last year he was 31, tormented by pain and backsliding. “We were at a point where there was not much more they could do,” he said.

One night he pulled out an offending tooth with the pliers on his Leatherman tool. Two nights later he removed another. When his mother, Gail Kirby, understood what he had done, she pleaded with him, asking what he wanted, what someone might do to help. “He said, ‘Mama, I want my face,’ ” she said.

In 2007, Doc attended a benefit dinner honoring veterans at the Waldorf Astoria. It was hosted by the Marine Corps-Law Enforcement Foundation, a private organization that provides college scholarships to the children of Marines and federal law-enforcement officers killed in the line of duty. He was the guest of Jack Doyle, an investment portfolio manager and foundation donor whose brother-in-law, Dennis M. Edwards, was killed in the terrorist attacks in 2001 on the World Trade Center. There Doc met a pair of brothers — a doctor and a dentist — who said that if he ever needed care, they would help. The dentist was a former Marine. Doc had mentioned the meeting to his mother, but in the ensuing years he thought little of their pledge. He forgot their names. “I just thought, That was nice of them to say,” he said.

Last September, despondent, his mother emailed Doyle. She warned that she was venting. She apologized for rambling. She said that if he did not want to read her long email, she would understand. And she told him about her son’s ongoing pain and problems, and asked whether he might connect her to the people he had met in New York in 2007 and who had offered help.

Ten days after that, Gail Kirby received an email from Dr. Spero J. Theodorou, a plastic surgeon in Manhattan and the doctor Doc met at the gala at the Waldorf. He asked for Doc’s medical file and then found Dr. Hirsch, who had pioneered virtual surgical planning and the use of precise three-dimensional models of a patient’s current and reconstructed bone structure to design custom titanium plates — technology that was not available when Doc was shot. He and Lenox Hill Hospital offered Doc the operation and said they would follow up with dental implants, giving him an aligned bite and mouth full of teeth.

The price for all this work typically ran to about $300,000. In Doc’s case, Hirsch said, the procedures and implants would be free. More generosity followed: a GoFundMe.com campaign to crowd-source donations for the families’ travel expenses, and grants from the Semper Fi Fund, which covers family costs for veterans as they recover from their wounds. (Disclosure: I donated $100 to the GoFundMe campaign.)

Early on the evening of the operation Teng and Dr. Todd Hanna, a fellow in oral and maxillofacial surgery, spent an hour suturing Doc’s face. The jaw reconstruction was over. The first four dental implants were in place. Dr. Hanna unpeeled the tape over Doc’s eyes, which had protected them from the operation’s debris, and the two surgeons rinsed the blood from Doc’s beard. They washed his face gently and prepared to slide him from the table to a rollaway bed, on which he would be moved to a recovery room for a reunion with his family.

Hirsch leaned over and put his mouth near Doc’s ear. “Dusty, we’re all done,” he said. “Are you O.K.?”

赫希弯下腰，把嘴凑到“医生”耳边。“达斯蒂（达斯汀的昵称——译注），我们做完了，”他说，“你还好吗？”

Doc stirred. He was semiconscious. With his left elbow on the operating table, he lifted his big tattooed forearm, formed a fist and slowly made a thumbs-up sign. He held it for a few long seconds. Then he clutched the surgeon’s hand.